Doses Flashcards
Glipizide
2.5-20mg po qd-bid; MDD= 40mg/d
XL: 5-10mg po qd; MDD= 20 mg/d
CrCl: <50; reduce dose by 50%
Glyburide
1.25- 20 mg po QD
MDD= 20 mg/d
Beers list; elderly can not use it (<50; do not use anymore
Glimepiride
1-4 mg po QD; MDD = 8 mg/day
CrCl <60; monitor
SU side effects
Hypoglycemia N/V Weight gain GI upset rash Cholestatic jaundice Hemolytic anemia
SU interactions
OH: flushing, potentiation of hypoglycemia
Displaced protein binding: salicylates, clofibrate, other SU
Decreased Renal excretion: allopurinol, probenacid - increasing concentrations of SU resulting in low BS
SU contraindication
Hypersensitivity DK Cl <50 (glyburide) Pregnancy- 3rd trimester ( glyburide and glipizide only) T1DM
SU counseling
take first thing in the morning 1/2 before breakfast
Take with food
Avoid OH use
A1C lowering of 0.8-2%
Low cost
Reduction in CV events and mortality
Disadv: hypoglycemia, wt. gain, myocardial ischemia preconditioning, low durability
Monitor: hypoglycemia, fbg, wt gain, allegoric reactions (sulfa), increased sun sensitivity
Meglitides : short acting SU
Repaglinide (prandin),
nateglinide (starlix)
Short acting secretagoges
Dosing:
Affect post prandial level: take with meals
Nateglinide: 60-120 mg po TID before meals
Repaglinide: 0.5-16 mg po before meals MDD= 16mg/day
SE: hypoglycemia, GI symptoms, headache, caution use in kidney and liver impairment
Meglitinides DDI
Nateglinide:
Mifepristone: do not use within 14 days
Pazopanib: increases nateglinide levels
Repaglinide:
Mifepristone: do not use within 14 days
Gemfibrozil: increases repaglinide levels
NPH insulin: increases risk MI (avoid)
Meglitinides CI
Hypersensitivity
T1DM
DKA
Meglitinides counseling
Administer after meals: 30 minutes:::::::if meal skipped dose skipped
Hypoglycemia & wt gain
Avg A1C lowering 0.6-1.0%
Sane as SU
Biguanides: metformin
Dosing
IR: 500, 850, 1000 mg
ER: 500, 750, 1000
MDD= 2550 mg/day
Increase muscle glucose uptake
Decrease glucose output from liver
850-2000 mg po qd-bid
Minimum effective: 500 mg po bid
Optimal dosing:
IR= 850- 1000 mg bid
ER= 1000-2000 mg qd
Given BID; and take with food to decrease SE
SE:
GI: NV, diarrhea
Wt. Loss: lactic acidosis <0.1/1000
Ask abt: SOB, muscle cramping, tachycardia
Biguanide DDI
Concentration of: dofetilide, dalfampridine, radioopague contrast dyes increase (stop metformin 24-48 hours before use)
”” decrease: trospium
Metformin concentrations increase with: cimetidine, trimethoprim, lamotrigine
”” decrease: luteinizing hormone
Biguanide CI
Hypersensitivity Renal disease/dysfunction Metabolic acidosis Dka Lactic acidosis Iodinated contrast Impaired liver function Hypoxemia Dehydration Sepsis Surgery
Metformin renal doses
CrCl: = 1.5 mg/dl in men and 1.4 in women
Biguanides
Advantages:
No wt gain or hypoglycemia,
Reduce in CV events and mortality
Low cost
Disadvantage: GI SE Vitamin B12 deficiency Renal function caution Lactic acidosis (rare)
Thiazolidinedoines
Rosiglitazone (Avandia)
Pioglitazone (Actos)
Decrease peripheral insulin resistance acting on muscle and adipose tissue
Take once daily; same time each day, avoid oh use
Rosiglitazone (Avandia): 4-8 mg po QD
MDD= 8 mg
Pioglitazone (Actos): 15-30 mg po QD
MDD= 45mg
Thiazolidinediones side effects/ DDI
Edema
Wt gain (>10 kg) esp with insulin or insulin secretagogues
Hepatic toxicity: rare
Rosiglitazone: insulin, nitrates (inc risk of MI= black box warning)
Pioglitazone: oral contraceptives decreased efficacy, progestins, pazopanib
Thiazolidinedoines Contraindications
Hypersensitivity/ T1DM/DKA ALT >2.5 ULN NYHA CLASS 3-5 HF ACS Active bladder disease
Thiazolidinediones
Increase HDL; decrease TG
NO HYPERGLYCEMIA
DISADVANTAGE's Wt gain Edema Hf Bone fracture Increase ldl: Rosi CV warnings
Alpha-glucose inhibitors
Acarbose (precose)
Miglitol (glyset)
Acarbose: 25 mg po TID; MDD= 50 mg po TID
Miglitol: 25 mg po TID; MDD = 100 mg po TID
Se: abd pain, diarrhea, flatulence
Alpha- Glucoside Inhibitors CI/ advant
CI: hypersensitivity, DKA, cirrhosis, IBS, clonic ulcerations, intestinal obstruction, Scr
Must take with meal
Advantages:
Not systemic
Decrease PPG
Disadvantage:
GI side effects (flatulence, gas, diarrhea)
Dose frequency
Medium cost
Gliptins (DPP-4 Inhibitors) Januvia (sitagliptin) Tradjenta (linagliptin) Onglyza (saxagliptin) Nesina (alogliptin)
Sitagliptin:
Optimal dose= 100mg qd
30-49 = 50 mg
<15 = 6.25 mg
Gliptins SE/DDI
Nasopharyngitis URI Diarrhea N/v Headache Pancreatitis? Hepatotoxicity
DDI -
Saxa: conivaptan increase con
Trajenta: carbamazepine, efavirenz, phenytoins, rifampins, st. Johns wort decreases con
JANUVIA AND NESIBA HAVE NO DRUG INTERACTIONS
Gliptins CI/ counseling
Hypersensitivity
T1DM
DKA
Take same time each day with or without food and avoid alcohol
Ask about nasopharyngitis and URI
Gliptins adv/disadv
Average A1c 0.6-0.8
No hypoglycemia
Wt neutral
Disadv
Uticaria/angioedema
Pancrititis
High cost and unknown safety
Monitor fbg/ppg
Uri and gi intolerance
SGLT-2
Invokana (canagliflozin)
Farxiga (dapagliflozin)
Canagliflozin: 100 mg po qd
Optimal dose is 300 mg qd
Use only if eGFR is 45-60
Dapagliozin: start at 5mg qam and move to 10mg qam
Avoid when gfr is 30-59
Take once daily same time each day
Canagliflozin side effects
Canagliflozin Yeast infections UTI Increased urination Male genital mycotic infection
Dapagliflozin
Same as canagliflozin
Nasopharyngitis
SGLT 2 DDI
UGT enzyme inducers
Rafampin, phenytoin, phenobarbital
ACE, arb, diuretics cause hypotension
SGLT 2 Contraindication
Dialysis
CrCl <30
ESRD
CAUTION: hyperkalemia with canagliflozin, LDL-C levels and bladder cancer with dapagliflozin
